- Email: [email protected]
Vascular headache. The headache associated with “vasomotor instability”
Annotations
Vascular
715
headache.
The headache
associated
The pain associated with changes in caliber of the arteries in and about the cranium has had a good deal of attention, especially since Harold G. Wolff6 imposed some order on the subject with his excellent book published in 1948. Such a ubiquitous symptom as headache deserves considerable attention. The pain associated with spontaneously occurring vasomotor reaction in thescalp isusually termed migraine. It is this condition that I will consider. I find that I derive a better understanding of any topic if I can examine it with low-power (rather than high-power) lens, so to speak. Accordingly, I would admit to the category of migraine man) spontaneously recurring bouts of pain in and about the head, neck, thorax, and abdomen, including such disorders as cluster headache or histaminic cephalgia (Harris’s migraine),6 facial neuralgia (hysterical face pain, as Engel has called it); pseuand abdominal migraine. In these condoangina, ditions it seems that there is something the matter with local vasomotor regulation, and episodic pain is the main symptom. Psychological factors. A psychological pattern of some uniformity can be derived in persons suffering these syndromes. Migraine patients are intelligent, tense, striving, orderly, perfectionistic people, inflexible in their attitudes. Their underlying problem is that they have not learned the constructive uses of aggressive feelings. Obstinacy is one of their best defenses. They are unaware of the security of the mind unembarrassed by unconscious rage. In their early life they have somehow been conditioned to depend on others for approval, and the) value other opinion more highly than their own. This gaining of approval from others, that is approval other than genuine and relaxed self-approval, is a difficult way of life. It is bound to fail in dealing with people (rather than things). Other persons cannot be expected to deliver emotional supplies with any consistency; undoubtedly the most satisfactory climes for the good life are those that originate from within. \\‘ith aggressive feelings converted into brooding or vengeful longing (the migraine sufferer’s memory is like that of the elephant!), little wonder that life is punctuated with minor explosions. The attack usually appears in a setting of angry feelings (unconscious) associated with sustained resentment, anxiety, and frustration, in what might be considered as a state of energy depletion. Migraine may be looked upon as a way of life. It should be noted that there are persons of comparable personality pattern who never have had migraine: the disorder is not that simple. The determinants of human behavior are always multiple. Although there are several factors involved in the production of headache, it can be shown that sociocultural events experienced as noxious precede the appearance of these headaches.
with
“vasomotor
instability”
Physiologic factors. Between attacks of migraine, when the subject is considered to be well, the extracranial vessels of the scalp and neck may be varying in tone and diameter. This is not found in people who do not have migraine. The migraine attack is accompanied by a state of vasoconstriction followed by one of vbsodilatation in and about the cranium. All sorts of neurological signs may appear as aura, most commonly they are in the visual apparatus. These are belived to result because of cerebral vasoronstriction. We now know that local vasodilation may be associated with pain, as the swelling vessel wall impinges upon pain fibers in the adventitia. Biochemical factors. But there is more to the matter than psychologic and vasomotor reactions. A powerful vasodilator substance “neurokinin,” accumulates in the walls of cranial vessels and adjacent perivascular tissues in relation to the migraine attack. This substance lowers the pain threshold and increases capillary permeability.‘*& Therapeutic factors. Since the chronic headache syndrome known as migraine is the result of a complex dynamic interaction between a geneticall) determined potential and constantly changing psychological, social, and chemical or physical ehvironments, therapy may be approached from a number of directions. Perhaps the most logical step in treatment might be termed re-education, which cannot be practiced unless it is based on a careful review of the patient’s story and the performance of a thorough physical examination. With the confidence gained from them (by patient and physician), the physician is prepared to launch into a simple explanation in nonmedical terms of the nature of the headache, based on the physiologic, biochemical, and psychological principles Jready enunciated. This may be all that is required to break up a series of vicious headaches. The assurance gained by the patient that he does not have some devastating disease, brain tumor mainly, re-inforced, to be sure, by the care with which the physician has evaluated the problem, may halt the trouble forthwith. Persons with migraine need some insight into their emotional patterns. Since the migraine patient is almost invariably intelligent, the general physician usually can bring him around to the realization that his overly conscientious attitudes do not constitute a pleasant way of life. Uncovering or insight psychotherapy usually is best left to the competent psychiatrist, well versed in the dynamics of behavior and possessing a proper meld of humility. Sometimes goals need to be limited since there is an irreducible minimum of people who have got to have some headache: it is the best bargain that they can achieve in their rigidly constituted way of hfe. Erik Erikson4 has defined such a relationship as that I‘. in which the observer
716
.4m. Heart 1. .Vovcmber. 1963
Annotations
who has learned to observe himself teaches the observed to become self-observant.” The treatment of the symptoms is to try to abort the attack early in its course. Drugs taken at the very earliest manifestations of an attack may achieve this. Sometimes, aspirin may serve this function. Persons free of cardiovascular disease may take the v-asoconstrictor drug, ergotamine tartrate, by one of several routes; by inhalation, by mouth, sublingually, rectally, or parenterally. If the attack is established, there is little to be done beside attempt to promote rest in a quiet, darkened room. Partial compression, with the thumb, of the carotid system on the same side as the head pain is effective in halting unilateral headache for as long as the compression is maintained; this may allow the patient to get to sleep. The patient usually awakes free of headache. An icebag over the carotid vessels may serve as well to reduce the thrust of the pulse (throbbing headache). The injection of a sedative drug may become necessary to promote sleep. Prophylactic treatment of the attacks of migraine may be useful, particularly of cluster headache, which is the type that recurs frequently. Ergotamine tartrate, usually 2, and occasionally 3, tablets of 1 mg. each per day, taken over a period of a week or two, may break up a series of closely recurring attacks. Because this drug is not well absorbed orally, it may be used in prophylactic symptomatic treatment by injection, sublingually, rectally, or by aerosol insufflation. The main untoward effect of ergotamine tartrate is its propensitv to induce nausea and vomiting; it is contraindicated in vascular disease, hypertension, pregnancy, kidney and liver disease, sepsis, and cachexia. If patients with frequent migraine attacks do not tolerate or respond to the usual symptomatic use of ergotamine tartrate, a course of methysergide maleate may be tried. This substance is an antiseotonin agent. The average daily dose is 4 to 8 mg. daily for a 3-week trial. Occlusive vascular disorder has resulted rarely with the use of methysergide meleate. Sedative, analgesic, and “tranquilizing” drugs
have limited uses in migraine. An occasional stubborn case may be transiently benefited with corticosteroids. Corticotropin in doses of 20 to 30 units has been known to abort weekly or monthly attacks of migraine. The corticosteroids should almost never be used in migraine. -1 variety of untoward circumstances are at work to result in an attack of migraine; these include personality problems, altered vasomotor tone, and the local production of a noxious agent or agents capable of lowering the pain threshold. The sheet anchor of treatment is a conscientious elicitation of history and the performance of a thorough-going physical examination. These simple measures are more often neglected than not. Their proper performance is the basis for a therpaeutic program; indeed, they are the first indispensable step in any treatment. Charles D. Aring, M.D. Department of Newology l~nirersity of Cincinnati College of Medicine Cincinnati, Ohio REFERENCES 1.
Aring, C. D.: Vascular headache, .A.M.A., Arch. Int. Med. 109:18, 1962. la. Chapman, L. F., Ramos. .A. O., Goodell, H., Silverman, G., and W’olff, FI. G.: A humoral agent implicated in vascular headache of the migraine type, .L\.M.A. .Arch. Neural. 3:223, 1960. 2. Engel, G. L. : Primary atypical facial neuralgia : an hysterical conversion symptom, Psychosom. Med. 13:375, 1951. 3. Engel, G. L.: Pseudoangina, .\M. HEART J. 59:325, 1960. 4. Erikson, E. H.: Childhood and society, New York, 1950, W’. W’. Norton, & Company, Inc., 307 pages. 5. Harris’s migraine or cluster headaches (Editorial) J.A.M.A. 171:1224, 1959. 6. Wolff, H. G.: Headache and other head pain, New York, 1948, Oxford University Press, 648 pages.
Exercise performance and cardiac surgery in uncomplicated atrial septal defect
An atrial septal defect in which the only hemodynamic manifestation is left-to-right shunting may be tolerated without symptoms and is compatible with excellent life expectancy.’ These facts may well cause the conservative physician to hesitate in recommending surgical closure. On the assumption that catheterization of the right side of the heart has been performed and has demonstrated the magnitude of shunting and the absence of
pulmonary hypertension, there is little to be gained from further hemodynamic study. A search of the literature does not provide a precise basis for assessment of long-term risks, since available studies do not provide data which justify the assignment of higher risks to individual patients within this group of uncomplicated cases. In effect, the decision is likely to be based on the quality of surgical treatment available, the presence or absence of symp-
Vascular
715
headache.
The headache
associated
The pain associated with changes in caliber of the arteries in and about the cranium has had a good deal of attention, especially since Harold G. Wolff6 imposed some order on the subject with his excellent book published in 1948. Such a ubiquitous symptom as headache deserves considerable attention. The pain associated with spontaneously occurring vasomotor reaction in thescalp isusually termed migraine. It is this condition that I will consider. I find that I derive a better understanding of any topic if I can examine it with low-power (rather than high-power) lens, so to speak. Accordingly, I would admit to the category of migraine man) spontaneously recurring bouts of pain in and about the head, neck, thorax, and abdomen, including such disorders as cluster headache or histaminic cephalgia (Harris’s migraine),6 facial neuralgia (hysterical face pain, as Engel has called it); pseuand abdominal migraine. In these condoangina, ditions it seems that there is something the matter with local vasomotor regulation, and episodic pain is the main symptom. Psychological factors. A psychological pattern of some uniformity can be derived in persons suffering these syndromes. Migraine patients are intelligent, tense, striving, orderly, perfectionistic people, inflexible in their attitudes. Their underlying problem is that they have not learned the constructive uses of aggressive feelings. Obstinacy is one of their best defenses. They are unaware of the security of the mind unembarrassed by unconscious rage. In their early life they have somehow been conditioned to depend on others for approval, and the) value other opinion more highly than their own. This gaining of approval from others, that is approval other than genuine and relaxed self-approval, is a difficult way of life. It is bound to fail in dealing with people (rather than things). Other persons cannot be expected to deliver emotional supplies with any consistency; undoubtedly the most satisfactory climes for the good life are those that originate from within. \\‘ith aggressive feelings converted into brooding or vengeful longing (the migraine sufferer’s memory is like that of the elephant!), little wonder that life is punctuated with minor explosions. The attack usually appears in a setting of angry feelings (unconscious) associated with sustained resentment, anxiety, and frustration, in what might be considered as a state of energy depletion. Migraine may be looked upon as a way of life. It should be noted that there are persons of comparable personality pattern who never have had migraine: the disorder is not that simple. The determinants of human behavior are always multiple. Although there are several factors involved in the production of headache, it can be shown that sociocultural events experienced as noxious precede the appearance of these headaches.
with
“vasomotor
instability”
Physiologic factors. Between attacks of migraine, when the subject is considered to be well, the extracranial vessels of the scalp and neck may be varying in tone and diameter. This is not found in people who do not have migraine. The migraine attack is accompanied by a state of vasoconstriction followed by one of vbsodilatation in and about the cranium. All sorts of neurological signs may appear as aura, most commonly they are in the visual apparatus. These are belived to result because of cerebral vasoronstriction. We now know that local vasodilation may be associated with pain, as the swelling vessel wall impinges upon pain fibers in the adventitia. Biochemical factors. But there is more to the matter than psychologic and vasomotor reactions. A powerful vasodilator substance “neurokinin,” accumulates in the walls of cranial vessels and adjacent perivascular tissues in relation to the migraine attack. This substance lowers the pain threshold and increases capillary permeability.‘*& Therapeutic factors. Since the chronic headache syndrome known as migraine is the result of a complex dynamic interaction between a geneticall) determined potential and constantly changing psychological, social, and chemical or physical ehvironments, therapy may be approached from a number of directions. Perhaps the most logical step in treatment might be termed re-education, which cannot be practiced unless it is based on a careful review of the patient’s story and the performance of a thorough physical examination. With the confidence gained from them (by patient and physician), the physician is prepared to launch into a simple explanation in nonmedical terms of the nature of the headache, based on the physiologic, biochemical, and psychological principles Jready enunciated. This may be all that is required to break up a series of vicious headaches. The assurance gained by the patient that he does not have some devastating disease, brain tumor mainly, re-inforced, to be sure, by the care with which the physician has evaluated the problem, may halt the trouble forthwith. Persons with migraine need some insight into their emotional patterns. Since the migraine patient is almost invariably intelligent, the general physician usually can bring him around to the realization that his overly conscientious attitudes do not constitute a pleasant way of life. Uncovering or insight psychotherapy usually is best left to the competent psychiatrist, well versed in the dynamics of behavior and possessing a proper meld of humility. Sometimes goals need to be limited since there is an irreducible minimum of people who have got to have some headache: it is the best bargain that they can achieve in their rigidly constituted way of hfe. Erik Erikson4 has defined such a relationship as that I‘. in which the observer
716
.4m. Heart 1. .Vovcmber. 1963
Annotations
who has learned to observe himself teaches the observed to become self-observant.” The treatment of the symptoms is to try to abort the attack early in its course. Drugs taken at the very earliest manifestations of an attack may achieve this. Sometimes, aspirin may serve this function. Persons free of cardiovascular disease may take the v-asoconstrictor drug, ergotamine tartrate, by one of several routes; by inhalation, by mouth, sublingually, rectally, or parenterally. If the attack is established, there is little to be done beside attempt to promote rest in a quiet, darkened room. Partial compression, with the thumb, of the carotid system on the same side as the head pain is effective in halting unilateral headache for as long as the compression is maintained; this may allow the patient to get to sleep. The patient usually awakes free of headache. An icebag over the carotid vessels may serve as well to reduce the thrust of the pulse (throbbing headache). The injection of a sedative drug may become necessary to promote sleep. Prophylactic treatment of the attacks of migraine may be useful, particularly of cluster headache, which is the type that recurs frequently. Ergotamine tartrate, usually 2, and occasionally 3, tablets of 1 mg. each per day, taken over a period of a week or two, may break up a series of closely recurring attacks. Because this drug is not well absorbed orally, it may be used in prophylactic symptomatic treatment by injection, sublingually, rectally, or by aerosol insufflation. The main untoward effect of ergotamine tartrate is its propensitv to induce nausea and vomiting; it is contraindicated in vascular disease, hypertension, pregnancy, kidney and liver disease, sepsis, and cachexia. If patients with frequent migraine attacks do not tolerate or respond to the usual symptomatic use of ergotamine tartrate, a course of methysergide maleate may be tried. This substance is an antiseotonin agent. The average daily dose is 4 to 8 mg. daily for a 3-week trial. Occlusive vascular disorder has resulted rarely with the use of methysergide meleate. Sedative, analgesic, and “tranquilizing” drugs
have limited uses in migraine. An occasional stubborn case may be transiently benefited with corticosteroids. Corticotropin in doses of 20 to 30 units has been known to abort weekly or monthly attacks of migraine. The corticosteroids should almost never be used in migraine. -1 variety of untoward circumstances are at work to result in an attack of migraine; these include personality problems, altered vasomotor tone, and the local production of a noxious agent or agents capable of lowering the pain threshold. The sheet anchor of treatment is a conscientious elicitation of history and the performance of a thorough-going physical examination. These simple measures are more often neglected than not. Their proper performance is the basis for a therpaeutic program; indeed, they are the first indispensable step in any treatment. Charles D. Aring, M.D. Department of Newology l~nirersity of Cincinnati College of Medicine Cincinnati, Ohio REFERENCES 1.
Aring, C. D.: Vascular headache, .A.M.A., Arch. Int. Med. 109:18, 1962. la. Chapman, L. F., Ramos. .A. O., Goodell, H., Silverman, G., and W’olff, FI. G.: A humoral agent implicated in vascular headache of the migraine type, .L\.M.A. .Arch. Neural. 3:223, 1960. 2. Engel, G. L. : Primary atypical facial neuralgia : an hysterical conversion symptom, Psychosom. Med. 13:375, 1951. 3. Engel, G. L.: Pseudoangina, .\M. HEART J. 59:325, 1960. 4. Erikson, E. H.: Childhood and society, New York, 1950, W’. W’. Norton, & Company, Inc., 307 pages. 5. Harris’s migraine or cluster headaches (Editorial) J.A.M.A. 171:1224, 1959. 6. Wolff, H. G.: Headache and other head pain, New York, 1948, Oxford University Press, 648 pages.
Exercise performance and cardiac surgery in uncomplicated atrial septal defect
An atrial septal defect in which the only hemodynamic manifestation is left-to-right shunting may be tolerated without symptoms and is compatible with excellent life expectancy.’ These facts may well cause the conservative physician to hesitate in recommending surgical closure. On the assumption that catheterization of the right side of the heart has been performed and has demonstrated the magnitude of shunting and the absence of
pulmonary hypertension, there is little to be gained from further hemodynamic study. A search of the literature does not provide a precise basis for assessment of long-term risks, since available studies do not provide data which justify the assignment of higher risks to individual patients within this group of uncomplicated cases. In effect, the decision is likely to be based on the quality of surgical treatment available, the presence or absence of symp-